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Dialectical Behavior Therapy

What is Dialectical Behavior Therapy (DBT)?

Dialectical Behavior Therapy (DBT) is a comprehensive, evidence-based psychotherapy initially developed by Dr. Marsha Linehan to treat Borderline Personality Disorder (BPD). Over time, its effectiveness has been recognized for a broader range of conditions characterized by intense emotional dysregulation, impulsive behaviors, and interpersonal difficulties. DBT is unique in its emphasis on balancing acceptance and change.

DBT is a modified form of Cognitive Behavioral Therapy (CBT) that incorporates elements of Eastern mindfulness practices. The “dialectical” aspect refers to the philosophical idea of synthesizing opposites – specifically, the tension between accepting oneself as one is, and simultaneously working to change. This balance is central to DBT, helping individuals move past rigid, “either/or” thinking.

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DBT is not just a talk therapy; it’s a skills-based treatment that teaches individuals concrete strategies to manage overwhelming emotions, improve relationships, and cope with distress in healthier ways.

Core Principles of DBT:

1

Dialectics

The core principle of balancing acceptance and change. This means validating a person’s experience while also pushing them towards growth and new behaviors. It addresses the “both/and” nature of reality (e.g., “I am doing my best, AND I need to try harder”).

Holistic Approach

2

DBT addresses multiple areas of a person’s life, including emotional, cognitive, behavioral, and interpersonal functioning.

Skills Training

3

A significant component of DBT involves teaching specific skills across four main modules: Mindfulness, Distress Tolerance, Emotion Regulation, and Interpersonal Effectiveness.

How DBT Works: The Treatment Modalities

A standard comprehensive DBT program typically involves four key treatment modalities, working in concert:

Individual Therapy:

Weekly one-on-one sessions with a DBT-trained therapist. The focus is on enhancing motivation, applying skills to specific life challenges, and addressing therapy-interfering behaviors. Diary cards are often used to track emotions, urges, and skill use.

DBT Skills Training Group:

This is a structured, psychoeducational group (usually weekly for 2-2.5 hours) where clients learn and practice the four core DBT skill modules. This is often led by two therapists.

  • Mindfulness: Learning to be fully present and aware of the moment, observing thoughts and feelings without judgment. This helps reduce suffering and increase appreciation.
  • Distress Tolerance: Developing skills to cope with intense emotional pain without resorting to destructive behaviors. This includes techniques for self-soothing, distracting, and improving the moment.
  • Emotion Regulation: Understanding, identifying, and managing intense emotions. Skills focus on reducing emotional vulnerability, increasing positive emotional experiences, and changing unwanted emotions.
  • Interpersonal Effectiveness: Learning how to ask for what one needs, say no effectively, and maintain self-respect in relationships while also building and maintaining healthy connections.

Phone Coaching:

Brief, in-the-moment coaching calls between sessions to help clients generalize skills to real-life situations and prevent problematic behaviors. This provides immediate support when clients are struggling.

Therapist Consultation Team:

The individual therapists meet regularly (e.g., weekly) to support each other, ensure adherence to the DBT model, and enhance their own skills and motivation. This helps prevent therapist burnout and ensures consistent treatment.

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Frequently Asked Questions:

While initially developed for BPD, DBT’s robust framework for emotional regulation and distress tolerance has made it highly effective for a range of conditions and challenges, including:

  • Borderline Personality Disorder (BPD): DBT is considered the gold standard treatment for BPD due to its effectiveness in reducing suicidal ideation, self-harm, and hospitalizations.
  • Chronic Suicidal Ideation and Self-Harm: For individuals struggling with persistent thoughts of suicide or engaging in self-injurious behaviors, regardless of a BPD diagnosis.
  • Eating Disorders: Particularly Bulimia Nervosa and Binge Eating Disorder, where emotional dysregulation often plays a significant role in disordered eating patterns.
  • Substance Use Disorders: Especially when co-occurring with other emotional or personality disorders, as DBT helps address underlying emotional triggers.
  • Post-Traumatic Stress Disorder (PTSD): Especially complex PTSD, where emotional dysregulation and interpersonal difficulties are prominent.
    Severe Depression and Anxiety: When traditional CBT has been less effective due to the intensity of emotional dysregulation or co-occurring personality traits.
  • Anger Management: For individuals who experience intense, uncontrollable anger outbursts.
  • Adolescents with Emotional Dysregulation: Adapted DBT programs are increasingly used for teenagers struggling with similar issues as adults.

DBT is a demanding but highly rewarding therapy. Ideal candidates typically exhibit the following characteristics:

  • Significant Emotional Dysregulation: Individuals who experience intense, rapidly shifting emotions that feel overwhelming and difficult to control.
  • Impulsive Behaviors: A history of impulsive actions, such as self-harm, substance abuse, disordered eating, or risky sexual behavior, often in response to intense emotions.
  • Interpersonal Difficulties: Chronic relationship problems, including unstable relationships, intense fear of abandonment, or difficulty maintaining healthy boundaries.
  • Chronic Suicidal Ideation or Self-Harm: This is a primary indicator for DBT, as the therapy is designed to reduce these life-threatening behaviors.
    Willingness to Commit: DBT is a comprehensive program requiring significant commitment to attending multiple modalities (individual, group, phone coaching) and completing homework.
  • Ability to Tolerate Distress: While DBT teaches distress tolerance, candidates should have a baseline capacity to engage in the therapeutic process even when uncomfortable.
  • Desire for Skills-Based Learning: Individuals who are open to learning and practicing concrete skills rather than solely focusing on past experiences.
  • History of Treatment Resistance: Often, individuals who haven’t responded well to other forms of therapy find success with DBT due to its comprehensive and structured nature.

DBT is less suitable for individuals who are not willing to participate in group therapy, cannot commit to the time demands, or are primarily seeking a less structured, more exploratory form of therapy. However, for those struggling with severe emotional and behavioral dysregulation, DBT offers a path towards building a life worth living.

While DBT is rooted in CBT, it’s specifically adapted for individuals with significant emotional dysregulation. Key differences include:

  • Emphasis on Acceptance: DBT places a strong emphasis on radical acceptance and validation, alongside change strategies.


  • Structured Components: Comprehensive DBT involves multiple modes of treatment (individual therapy, skills group, phone coaching).


  • Specific Skill Modules: DBT teaches four core sets of behavioral skills in a highly structured manner.

DBT is a safe and highly effective therapy. However, because it involves confronting intense emotions and challenging long-standing patterns, it can sometimes feel emotionally uncomfortable or even more distressing in the short term. This is often a sign that important work is being done. Your therapist will provide support and guidance to help you navigate these challenges safely.

Yes, “homework” is a critical part of DBT! You’ll be asked to complete diary cards to track your emotions and behaviors, and to practice the skills learned in group and individual sessions in your daily life. Consistent practice is essential for integrating the skills and seeing lasting change.

In the United States, laws like the Affordable Care Act (ACA) and the Mental Health Parity and Addiction Equity Act (MHPAEA) require most insurance plans to provide equal coverage for mental health services as they do for physical health services. This means if your plan covers medical treatments, it should also cover evidence-based mental health treatments like DBT. The best way to know your coverage options is to call your insurance company directly [see tips here for verifying coverage with insurance companies].